Michelle L. Overfelt, MD

When I receive changeover on an emergency department patient who already has a plan of care, I almost never get involved unless the patient's status changes or the doctor handling that patient asks me to. This is a practice born out of necessity due to the large number of patients who pass through our ED. It's not a bad practice, because I'm fortunate enough to work with conscientious physicians whose judgment I trust. Once, however, it almost resulted in tragedy. 

The day I met "Sarah" began chaotically. One of my three preschoolers misplaced my car keys, and I drove to the wrong campus to begin my shift. Fortunately, at 7:10 a.m. the ED was relatively slow and I was able to delay seeing new patients until receiving changeover from my partner.  

Sarah had been found in a puddle of blood inside her apartment. When the paramedics arrived, she told them that she'd begun bleeding profusely while straining to have a bowel movement; she'd passed out, then called 911 upon regaining consciousness. At first she said that she was feeling much better and refused to be transported. She was very weak, though, and was ultimately persuaded to get into the ambulance. 

Still, when she'd finally allowed my partner to do a pelvic exam, he was horrified by what he saw: She had deep lacerations on her external genitalia, and her bleeding was so heavy, an adequate exam with repair simply couldn't be done in the ED. So he packed the wounds and contacted the gynecologist on call, who agreed to surgically repair the damage later that morning. 

When I arrived, my partner told me, "Something's fishy with her story. She's too evasive and disfigured. Why don't you take a look at her?" 

That's how he said it, really casual. "Maybe she tried to do a home abortion," I suggested. 

"Perhaps, but she's in her mid-20s with a job and health insurance. Not someone who's likely to self-abort. But I do think she's hiding something." 

Resisting a task until it's almost too late

I agreed to look at Sarah, then dove into the pile of patients that had accumulated during our changeover discussion. Before I knew it, all of my rooms were full and the waiting area was backed up. As I came out of a patient's room to answer a page, I noticed an OR nurse standing in Sarah's room. She had the consents for surgery and general anesthesia and was helping Sarah transfer to an OR bed. I looked at the clock. It was a little after 9 a.m. 

Had two hours really passed since I'd agreed to examine her?

The gynecologist who was scheduled to do the repair was a competent clinician and I felt that I wouldn't be contributing much to Sarah's care by getting involved this late in the game. In fact, it would seem awkward and rude to halt her transfer to the OR so that I could "take a look." 

My justifications for not examining her didn't end there. The numerous patients I was attending to at the time included a hospital maintenance worker who had sustained a globe rupture, a man with a near amputation of his hand, and a woman with an infected gallbladder who had just become hypotensive.  

As I watched the OR nurse move Sarah to another bed, I tried to convince myself that my partner would understand. I'd gotten too busy. She had been resting comfortably after a morphine injection and I didn't want to disturb her. The gynecologist was about to see her upstairs and her opinion was more valuable than mine. 

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It's easy for a "changeover" patient to fall through the cracks. The author's glad she went back to check.

Author | Michelle L. Overfelt, MD

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